Prolonged exposure therapy is more effective at treating PTSD than Seeking Safety, a coping skills therapy, for patients who also have alcohol use disorder, found a VA San Diego Healthcare System study. The findings offer important guidance for clinicians in the VA health care system, which cares for many veterans coping with both PTSD and problem drinking.

The researchers compared patients who were given integrated alcohol and prolonged exposure treatment with those given integrated alcohol and coping skills treatment. Both treatments reduced PTSD symptoms and heavy drinking. But patients receiving prolonged exposure therapy had significantly lower scores on a measure of PTSD symptoms. The researchers concluded that prolonged exposure therapy should be offered to patients with PTSD whenever possible, including to patients with alcohol use disorder.

The results will appear in the April 24, 2019, issue of JAMA Psychiatry.

The study was led by Dr. Sonya Norman, a researcher at the San Diego VA, director of the PTSD Consultation Program for the National Center for PTSD, and a professor of psychiatry at the University of California San Diego. Norman explained that the results could lead to better treatment for PTSD. "The research is not showing concerns that PTSD patients with alcohol use disorder can't handle exposure to be true," she said. "The main takeaway of the study for me is that we may be doing a disservice to veterans if we don't offer them the best treatments we have available for PTSD, such as prolonged exposure."

PTSD and alcohol use disorder commonly occur together. A 2011 study by San Francisco VA Medical Center researchers found that 55% to 75% of Iraq and Afghanistan veterans receiving care through VA who had an alcohol or substance use disorder also had a PTSD or depression diagnosis. They are both linked to psychiatric and personal problems. People with both PTSD and alcohol use disorder tend to have shorter periods of abstinence from drinking. They also have a greater risk of suicide and homelessness, as well as more legal and psychological problems, than people with only one of the conditions.

Prolonged exposure therapy is considered a gold standard for PTSD treatment. In this psychotherapy, patients gradually approach memories, feelings, and situations related to their trauma. The goal is for them to be able to face memories and thoughts related to trauma without triggering anxiety and stress.

Much research has shown prolonged exposure therapy to be the most effective treatment for PTSD. However, many patients with both PTSD and alcohol use disorder are not offered the treatment, according to the researchers. Therapists are often concerned that exposure to traumatic memories may lead to increased drinking.

Seeking Safety, a widely accepted psychotherapy for co-occurring PTSD and alcohol use disorder, focuses on coping skills rather than exposure. The thought is that establishing safety through better coping skills is the first priority, and that eliciting traumatic memories too early may be harmful—and may trigger drinking.

To compare the two approaches, researchers recruited 119 patients with both PTSD and alcohol use disorder. One group was given integrated prolonged exposure therapy, and a second group was given Seeking Safety. Both types of treatment incorporated cognitive behavioral intervention for alcohol use disorder alongside the PTSD psychotherapy.

Both interventions led to fewer days of heavy drinking and a decrease in PTSD symptoms, as measured by the Clinician Administered PTSD Scale-5. While both treatments lowered PTSD symptoms, patients who received prolonged exposure had significantly lower PTSD symptom scores, as well as higher rates of PTSD remission.

Immediately after treatment, 22% of prolonged exposure patients had achieved PTSD remission, compared with 7% in the coping skills group. Three months after treatment, those numbers were 25% versus 6%. After six months, 33% of prolonged exposure patients were in remission, while only 15% of coping skills patients were.

Patients in both groups reported high levels of satisfaction with their treatment. Patients in both groups also had fewer heavy drinking days after treatment. This reduction in drinking was not significantly different between groups, contrary to the researchers' expectations. They speculate that this result could be due to the similarity between the cognitive behavioral interventions used for each group. Although the prolonged exposure group did not have less heavy drinking than the coping skills group as the researchers expected, exposure therapy did not lead to increased drinking, as many experts in the field might think it would.

The results show that prolonged exposure therapy is more effective at treating PTSD than treatment without exposure regardless of whether patients also have alcohol use disorder, say the researchers. They conclude that many patients may not be getting the most effective treatment because of their alcohol use disorder.

Coping skills therapy still has its uses, according to the researchers. Coping skills therapy may be useful when patients refuse prolonged exposure or when prolonged exposure is not available, but the researchers say their results suggest that prolonged exposure should be the first line of treatment for patients with PTSD and alcohol use disorder.

Research into prolonged exposure therapy continues. "The next stage of this research," explained Norman, "is to learn how to make prolonged exposure even more effective for patients with PTSD and alcohol use disorder. We are now conducting a study where we are combining medication to help reduce drinking with prolonged exposure to see if the combination helps patients complete prolonged exposure and benefit even more from the treatment."

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